Despite the high incidence rates of cervical cancer and low screening prevalence among Asian American women, few programs to increase cervical cancer screening have been developed for these populations. Of the various programs that have been evaluated, the majority has been targeted toward Vietnamese American women64-69
and is community-based. For example, using a two-community controlled design, an intervention comprised of lay health worker outreach, health fairs, and culturally-appropriate educational materials was evaluated in one community (San Francisco) relative to a comparison community (Sacramento).64, 67
This program yielded promising results by demonstrating a 20% increase in Pap test screening rates in the intervention community.64, 67
To reach a larger number of individuals in the community, several programs have utilized media-based approaches. In one such study, a media-based community education program was launched to increase breast and cervical cancer screening among Vietnamese American women residing in specific counties in California.65
At post-intervention, results suggested that the media campaign had significantly increased intention to undergo cervical cancer screening, but it did not result in meaningful differences in actual screening rates.
Hence, it has been proposed that a combined approach will yield greater impact on cervical cancer screening rates.66, 68-69
Studies employing a combined approach have generally intermixed media campaigns with a lay health worker outreach program. Such combined interventions have been found to result in greater increases in uptake of Pap testing compared to media-based education only.68
Taken together, these findings suggest that media campaigns can increase women’s awareness of cervical cancer screening, but more intensive strategies (such as using lay health workers to encourage and assist women in obtaining screening) are needed to translate awareness into behavior.
Other studies are attempting to address the need for more intensive and effective strategies by partnering with community-based networks. Guided by the principles of community-based participatory research (CBPR),70
Ma and colleagues are conducting a large-scale, community-based randomized intervention trial to increase cervical cancer screening and reduce health system access barriers among medically-underserved and low-income Vietnamese American women residing in the eastern region of the US. Although final outcome data are not yet available, preliminary analyses indicate a significant increase in Pap testing rates among non-compliant women in the intervention group compared to the control group at 12-months post-intervention. Further, two major lessons were learned from this research experience. First, efforts to reduce health disparities do not need to be limited to health professionals. Engaging community-based organizations within the targeted populations from program concept and development to implementation are critical elements in building the essential links, trust, and respect required for successful, long-term partnerships and high-quality research. Indeed, the engagement of community gatekeepers and organizations fostered broader community interest and enhanced participation in the resulting programs. Second, the input received from community partners resulted in the incorporation of comprehensive intervention strategies that were used to address a broad range of identified barriers and attitudinal beliefs at both the individual- and system-levels. This comprehensive approach, in turn, increased the community’s utilization of the education and screening programs developed.
The programs described above were developed specifically for Vietnamese American women, but given empirical evidence that Chinese American women experience numerous and varied barriers to screening, there has also been significant interest in the development of interventions to address such barriers in this population. Along these lines, Taylor and colleagues conducted a randomized trial to evaluate the impact of a “high-intensity” outreach worker intervention.71
Chinese American women who were randomized to the “high-intensity” intervention received Chinese language educational materials, tailored counseling delivered by a Chinese outreach worker during a home visit, and logistical assistance as needed (e.g., assistance with appointment scheduling, medical interpreter services during clinic visits, transportation assistance). A “low-intensity” intervention arm consisted of a direct mailing of the educational materials that were provided in the “high-intensity” intervention, and a third group of women were randomized to a control condition of usual care. Follow-up assessments indicated a modest increase in screening among all three study arms, but overall screening rates remained low.71
Lack of access remained a significant barrier to screening in this population. Therefore, in addition to the logistical assistance offered by the outreach workers, there is a need for greater navigation services, particularly with respect to helping women identify state- or federally-funded programs that provide free or low-cost cancer screening and prevention services for underserved women.
The provision of navigation services, combined with community-based education, was evaluated in a study conducted by Ma and colleagues. In a study of Chinese American women residing in New York City,72
women were randomized to either an intervention program designed to reduce access barriers or to a general health education comparison group. Women in the intervention group received bilingual group education, interaction with a Chinese physician, and navigation assistance, including help with identifying and accessing free or low-cost screening services. The comparison group received education delivered by Chinese community health educators and written materials on general wellness and cancer screening, including cervical cancer, the Pap test, and information about sites that provided free screening. At the 12-month post-intervention assessment, screening rates were significantly higher in the intervention group (70%) compared to the control group (11%).72
Thus, a community-based program that provided both education and navigation services can be effective in overcoming the extensive linguistic and access barriers to screening faced by Chinese American women.
Fang and colleagues used a similar “combined” approach, targeting both individual-level factors (e.g., beliefs about screening and cancer) and healthcare access barriers, to increase cervical cancer screening rates among Korean American women.73
In this study, women recruited from community-based organizations received either a combined intervention or general health education. In the intervention condition, small-group education was delivered by bilingual community health educators using visual aids and materials in the Korean language. In addition, these educational workshops were combined with patient navigation assistance (e.g., language services, appointment scheduling, transportation assistance), referrals to Pap-test sites, and a 6-month reminder for screening. The intervention materials addressed key beliefs and perceptions such as perceived susceptibility to and perceived severity of cervical cancer, and the perceived benefits and barriers to screening. As such, the intervention program was designed not only to address group-specific health beliefs and psychosocial barriers to screening, but also adapted the patient navigator concept for preventive care. Results indicated that screening rates increased significantly among women in the intervention group compared to the control group.73
Other studies that have focused on enhancing cervical cancer screening among Korean American women have yielded somewhat mixed results.74-75
For example, a 4-year community intervention was implemented to promote both breast and cervical cancer screening among Korean American women residing in California.74
The intervention, which consisted of workshops, educational materials, and financial incentives for screening, did not enhance overall screening rates in the intervention community relative to the comparison community, but attendance at workshops was found to be associated with higher rates of cervical cancer screening.75
These findings are consistent with prior studies that have reported that although educational workshops can lead to modest increases in screening, lack of access remains a significant barrier to screening in Asian American women.
In summary, a limited number of interventions to enhance cervical cancer screening have been developed and implemented among Vietnamese, Chinese, and Korean American women. Several of these have utilized media campaigns, either alone or in combination with a lay health worker outreach program. Though media campaigns may reach a larger number of individuals, the results suggest that media campaigns alone are not sufficient to increase cervical cancer screening rates. The majority of studies reviewed utilized some combination of lay health worker training, educational workshops, and culturally- and linguistically-appropriate materials. These programs tended to have greater success, although the observed increases in screening rates were modest if access barriers were not adequately addressed. Intervention programs that addressed access barriers directly (through provision of navigation services) demonstrated the largest increases in screening rates.